ENT Emergencies in Primary Care PDF

ENT Emergencies in Primary Care Otologic Disorders: External Ear (cartilage, auricle and external auditory canal) - Auricle - Hematoma: can cause cartilaginous necrosis - Commonly seen in athletes (wrestling) - Treatment: **drain quickly**, antibiotics, bulky ear...

ENT Emergencies in Primary Care Otologic Disorders: External Ear (cartilage, auricle and external auditory canal) - Auricle - Hematoma: can cause cartilaginous necrosis - Commonly seen in athletes (wrestling) - Treatment: **drain quickly**, antibiotics, bulky ear dressing **(bolster) so it doesn't reform,** close follow up, or else necrosis of cartilage and cauliflower formation of auricle will develop - Lacerations - Treatment: Single layer closure, close both skin and perichondrium with bulky dressing if just on one side. If both sides, both sides should be closed - Otitis Externa: Caused by bacteria (p. aeruginosa, S. aureus) or fungus (A. niger) of external ear - Extremely painful, in swimmers - Bacterial: Most caused by pseudomonas, more pain/swelling than fungal - Fungal: could be in patients being treated for bacterial infections - Drainage: exudate that is white with black spots, not a lot of canal edema, lots of debris - Treatment: Removal of debris and cleaning, **topical drops** (antibacterial or antifungal), not oral. Use wick for tight canals or cannot see tympanic membrane - Diabetes/Immunocompromised patients: Malignant otitis externa can occur (skull-based infections, are toxic, multiple cranial nerve deficits) - Foreign Bodies of Ear Canal - Insects can crawl into canal or patient puts something in ear - Treatment: mineral oil or lidocaine to kill insects. Remove head for ticks- send to ENT for ticks (has to be shocked). If object, remove with forceps and suction if it can be easily removed, less is more. If insect killed, patient is stable, can follow up in 2 days with ENT for removal. If foreign body, almost never emergency, make a referral and don't try too hard to remove - Tympanic Membrane Perforations- A top concern with otologic emergency - Can have a history of drainage - Usually caused by middle ear pressure secondary to fluid, infection, or barotrauma. Can be from external trauma (q tip). Most heal uneventfully, but need otologic follow up for persistent perforation or hearing loss - Perforations with vertigo or facial nerve involvement need immediate referral: facial nerve goes through middle ear space and can be injured - Treatment: antibiotics, avoid gentamycin or neomycin drops (can be ototoxic). Quinolone drops are safe - Can make diagnosis if history is right and only see drainage Otologic Disorders: Middle Ear (Sound conduction, tympanic cavity, ossicles, auditory tube) - Otitis Media- Infection of middle ear effusion (viral or bacterial, but usually viral) - Treatment: antibiotics - Complication to watch for: - Mastoiditis: Venous connection with brain, need aggressive treatment. Mastoid airspace will fluid in it with every acute otitis media patient. - **Clinical diagnosis** based on examination of ear protrusion, severe pain behind ear, and erythema. - Treatment: Aggressive. Don't need radiological proof, surgical intervention, refer to ENT for mastoidectomy - Seventh Nerve Palsy (Bell's Palsy) - Rule out treatable and known cases: Acute otitis media, Ramsey Hunt (HZV), Lyme's Disease - Watch for acute otitis media involving facial nerve palsy, needs immediate and aggressive treatment - Treatment: treat underlying condition (acute otitis media), **steroids (start immediately),** antivirals/antibiotics, surgical decompression (usually not necessary) - Otologic Disorders: Inner Ear: (Balance and hearing, cochlea, vestibular, auditory and facial nerve) - Acute Labyrinthitis (very common) - Acute onset, usually no signs and young patients, horizontal nystagmus - Treatment: Supportive, vestibular suppressants (antihistamines like meclizine or benzos), steroids (short courses) - BPPV - Positional, recurrent, rotational nystagmus - Canalith repositioning maneuver, Eplys maneuver, physical therapy - New Onset Meniere's- to watch for (pressure problem of inner ear) - Vertigo, sudden **onset of sensorineural hearing loss**, tinnitus, unilateral hearing loss - Treatment: Benzos (vestibular suppressants) steroids, sodium restriction, fluid, rest - Careful with benzos in older patients, but a low dose benzo treats vertigo better than antihistamines - Sudden Hearing Loss - **When to worry:** Unilateral, no pain, associated with vertigo (emergency) - Rule out otitis media, cerumen - Treatment: **steroids immediately** - Nasal Disorders - Anterior Epistaxis (Kiesselbach's Triangle 90% of cases) - Etiologies: Trauma, dryness, allergies, Flonase, pregnancy - Do not treat with Flonase - Respond well to pressure, packing, cauterize, tamponade (all packing requires antibiotic prophylaxis) - Posterior Epistaxis: Most are arterial - Etiologies: Coagulopathy, hypertension, atherosclerosis, neoplasm - Do not respond well to anterior packing/pressure, bleed out the other side, bleed out of eyes, hemotympanum, continues to bleed because arterial - Evacuate the clot (can cause localized DIC reaction), topical vasoconstrictors and anesthetics, most require admission for cardiac and oxygen monitoring (bradycardia, hypoxia), need balloon with ribbon packing - Internal Maxillary Artery Embolization - Endoscopic Sphenopalatine Artery Coagulation - Sinusitis - Complications are an emergency: Orbital cellulitis and abscess is most concerning. Seen with lit edema, unilateral movement of orbits laterally and inferiorly. Can get meningitis and brain abscesses. Surgical drainage is often necessary, CT, and ED referral - Facial, Oral, and Pharyngeal Disorders - Facial Cellulitis - Most commonly from S. pyrogens and S. aureus, occasionally H. influenza - Progress very rapidly, need to be monitored and closely followed up with, or else may need admitted for IV antibiotics - Pharyngitis- not an emergency - Viral (EBV, CMV, Adenovirus), or bacterial (GABHS (strep), mycoplasma, gonorrhea, diphtheria) - Treatment: supportive with antibiotics - Peritonsillar Abscess: Infection adjacent to pharyngeal tonsil - Unilateral displacement of tonsil inferiorly and medially. Displacement of uvula to other side. Have **trismus** and some degree of ear pain and muffles voice, dysphagia - Treatment: Iv antibiotics and steroids, ENT referral - Retropharyngeal Abscess - Pain, dysphagia, fever, dyspnea, common in children - Lateral Xray will show swelling of retropharyngeal space - Complication: **Mediastinitis** (need admitted, emergency) - Treatment: Needle drainage/Open I/D - Masticator-Parapharyngeal Space Infection: Infection of lower molars that extend into masticator space - Usually associated with dental infections - Swelling, pain, fever, **trismus** - If bad tooth/rotten rigidity, trismus, need to think this infection - Treatment: Open I/D, IV antibiotics - Airway Obstruction Types - Stridor: Inspiratory: incomplete upper airway obstruction - Wheezing: Expiratory: incomplete lower airway obstruction - Aphonia/No air movement: Complete upper airway obstruction (serious) - Loss of breath sounds in lower air fields: Complete lower airway obstruction - Upper Airway Obstruction Diseases - Ludwig's Angina: Have very severe cellulitis that results in rapidly progressive swelling of the floor of the mouth - Usually in debilitated patients or precipitated by dental procedures - Impending airway obstruction: refer to ED for airway management, IV antibiotics - Angioedema: Hereditary and related to ACE inhibitors, occasionally life threatening - Treatment: Steroids, antihistamines, doxepin - Hereditary (relapsing)- C1-esterase deficiency: Warn about relapsing problem even after getting off ACE inhibitor - Surgical intervention rarely needed - Epiglottitis: Seen in older children and adults now secondary to HIB vaccine - Onset is rapid: They will look toxic - Muffled voice, prefer to sit, dysphagia, drooling, restlessness, swollen epiglottis with thumbprint sign on imaging - Treatment: Avoid agitation, be ready to secure airway, IV antibiotics, steroids, soft tissues of neck, prepare for emergent airway securement. - Laryngeal Obstruction: Rare - Subglottic stenosis infections (croup) and trauma can cause airway obstruction (narrowest part of airway) - Present with stridor, so laryngeal cancers are rare to be undetected, supraglottic larynx is one exception since they appear asymptomatic for a long period of time - Emergent Surgical intervention: Airway goes down, further away from skin, and posterior, so closer to cricothyroid membrane and thyroid cartilage, closer to skin, so cricothyroidotomy is preferred method of achieving surgical airway since less time to travel to airway. Extend the neck, stay midline, go through cricothyroid membrane